Reply

We read the interesting Letter to the Editor by Lim et al.(1) We would like to thank sincerely the authors for their kind attention. They are indeed right to mention that other groups contributed to this field of liver transplantation (LT): an initial series of auxillary partial heterotopic and auxillary partial orthotopic liver transplants (APOLT) using deceased donor and living donor grafts were reported by Terpstra et al. and Broelsch et al.(2,3) Recently, Line et al.(4) reported on a patient with colorectal liver metastasis who underwent segmental LT with a left lateral split liver graft and a 2stage hepatectomy following the associating liver partition and portal vein ligation for staged hepatectomy concept.(5) This novel strategy was described as the “RAPID concept” (resection and partial liver segment 24 transplantation with delayed total hepatectomy). Our report describes the RAPID procedure performed in the living donor liver transplantation (LDLT) setting for a patient with cirrhosis with portal hypertension and hepatocellular carcinoma (HCC). It definitely is a different procedure than the procedure the authors claim they performed in 2005 and more recently in 2016. Those were in fact APOLT procedures from deceased(6) and living donors,(7) the latter unfortunately with quite dismal results. In these articles, portal diversion, or any attempt to control portal hyperperfusion, was not performed, and the diseased livers could not be resected or were resected after 3 months, a point in time when portal hypertension gradually resolves. Their outcomes reflect the consequences of insufficient realtime measurement of portal pressure, flow and inaccurate interpretation of graft inflow hemodynamics, without any effort to implement graft inflow modulation (GIM). The procedure we reported, with a different methodology, focuses on efforts to optimize the concept of graft regeneration triggered by deportalization of the liver with the control of resulting portal hyperperfusion. The importance of deportalization and GIM to manage smallforsize syndrome (SFSS) grafts was understood and implemented during the technical evolution of these procedures. In fact, first described by the Kyoto group in the (LDLT) setting, with evolving experience, the importance of deliberately decreasing the portal flow to the diseased liver was understood.(8) In a series of 15 patients with 6 preserved and 9 diverted portal blood flow with native liver portal vein transections, they showed improved outcomes with diversion of the portal flow.(8) The procedure we reported, with a different methodology, focuses on efforts to optimize the concept of graft regeneration triggered by deportalization of the liver with the control of resulting portal hyperperfusion. I also disagree with Lim et al. regarding their concept of “the left lobe may act as a portosystemic shunt ‘with normal hepatocytes around’ that can spontaneously favor the flow into the graft and leads to right liver atrophy without the need of portal inflow modulation....” This is a misinterpretation of the importance of portal hyperflow and its consequences on SFS grafts. Indeed, our report, taking the RAPID concept 1 step further, additionally documents and describes an effective way to deal with extreme portal hyperflow, in order to provide successful graft hypertrophy. We again thank Lim et al. for suggesting that there has been another series published with the same methodology. However, the article by Wang et al. also describes APOLT cases of SFS LDLT grafts without deportalization of native livers or any GIM.(9) Their report nicely shows the gradual resolution of portal hyperflow, where diseased right lobes were preserved. However, noticeably 1 case developed an HCC recurrence. This unfortunate complication very clearly indicates the importance of removing the diseased remnant liver in a reasonable time. Address reprint requests to Deniz Balci, M.D., General Surgery and Organ Transplantation, Ankara University, Ibni Sina Hastanesi, Adnan Saygun Cad., No:51, Altindag, 06590, Ankara, Turkey. Telephone: +90 3125082842; E-mail: dbalci@medicine.ankara.edu.tr